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Develop a personal process to integrate new ideas, techniques into patient care
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Hip arthroscopy has become the most exciting new arthroscopic procedure among practicing orthopedic surgeons. The number of patients who underwent hip arthroscopy has increased dramatically during the last decade, with one study demonstrating a 365% increase from 2004 to 2009. Furthermore, the study’s researchers found most patients were young, active, working individuals — both men and women — between the ages of 20 years and 39 years.
Despite the broad introduction of the procedure throughout the United States, the Western region demonstrates the greatest incidence of hip arthroscopy procedures as if the conditions treated by this relatively new procedure are more prevalent on the West Coast. Small area variations in surgical procedures are not unusual, but the trend calls into question the process by which orthopedic surgeons acquire and incorporate new skills and technology into surgical practice before evidence-based information clearly defines the indications and benefits. As is often the case with new technology, the initial publications focus on the technique and then the outcomes of a series of patients from specialists. This is slowly followed by better designed studies to clearly define the indications, outcomes, complications and incorporation of the technology in the disease management of a patient population who was seemingly barely recognizable a decade ago.
Anthony A. Romeo
Motivation, financial incentives
An underlying motivation to any new technology can be the financial incentives right below the surface of this new advancement. Industry is highly motivated to seize any opportunity for a new market, with new instruments, implants and supportive devices being created as quickly as possible — most commonly with the assistance and guidance of orthopedic surgeon thought-leaders. Following closely behind the developments are industry-sponsored meetings to teach the new procedures, as well as continuing medical education meetings that would not exist without educational grants and other support from its industry partners.
It is not unusual for new procedures to be granted higher reimbursements for unlisted codes or codes, which when compared to previous “less-advanced” technology, are worthy of increased reimbursement as the practice is willing to be aggressive with insurance contract negotiations and modern revenue cycle management. With these incentives, the U.S. market remains responsible for more than 50% of the worldwide market regarding orthopedic devices. With a continued growth of the worldwide market close to 10% per year, the market will increase from a value of $36 billion in 2010 to an estimated $60 billion in 2017. Industry, orthopedic surgeons and patients are all seduced by the allure of new technology, which may mean better care and improved outcomes by many different measurements.
Fascination, challenges
Hip arthroscopy and the orthopedic surgeons who perform it are just one part of an orthopedic community that has demonstrated a fascination with new technology for many decades. Twenty-five years ago, many fellowships that provided education for shoulder surgery were the most sought-after educational programs. Initially, the procedures were related to the visualization of various structures in the shoulder, confirming the diagnosis, debriding torn tissues, then opening the shoulder to reconstruct the torn labrums, ligaments or tendons. Within a decade, there was an incredible explosion of education related to the treatment of shoulder problems with advances in the diagnosis, arthroscopic instruments, implants, sutures and techniques to repair almost any problem in the shoulder with minimally invasive arthroscopic surgery.
Hip arthroscopy may be in that steep growth curve that was seen with shoulder arthroscopy 20 years ago, although there are some potential disincentives that may severely limit its full incorporation into general orthopedic surgeons’ practices. The disincentives may include a perceived extended learning curve as many thought-leaders have suggested orthopedic surgeons need to perform 100 or more cases before they are comfortable with the primary procedures. Long patient preparations and positioning times are needed in the operating room, and it can be more difficult for an orthopedic surgeon to access the joint and understand the surrounding structures so iatrogenic injuries may be more common than with shoulder arthroscopy. There is a significant increase in radiation exposure due to the frequent use of fluoroscopy. The patient population is challenging as they often have poorly defined groin pain and a variety of differential diagnoses, such as low back pain, abdominal pain and urogynecological issues.
Third-party payers have challenged the indications and efficacy of hip arthroscopy, as well as the management of femoroacetabular impingement syndrome. Reimbursement has been denied in some states, although a number of interested parties, including surgeons, orthopedic societies and industry, have provided an aggressive defense of the treatment.
Diffusion of innovation
To understand the process of diffusion of innovation, we can divide ourselves into one of five groups: innovators, early adopters, early majority, late adopters and laggards. At this time with hip arthroscopy, we are in the area defined as early adopters and early majority. It appears many orthopedic surgeons are waiting to see if the hype will match the value before providing this care in their practice as less than 5% of orthopedic surgeons perform hip arthroscopy.
As with many new procedures or technology, orthopedic surgeons are intrigued by the idea and its potential, but temper their enthusiasm based on a number of factors. If we assume the procedure will be reasonably covered by insurance so financial issues are not a major concern, then the driving force behind the incorporation of any new technology should be the science that supports the technology and the education needed to incorporate the process into clinical practice. With multiple education courses at the Orthopedic Learning Center, as well as private and industry-sponsored cadaver-based hip arthroscopy courses, orthopedic surgeons have the opportunity to learn safe techniques and practices from a variety of sources. As for the science of hip arthroscopy, this month’s Cover Story, demonstrates that better scientific information with higher levels of evidence has increasingly populated the literature of the past 5 years.
It appears the number of orthopedic surgeons who will incorporate hip arthroscopy into their practices will remain relatively small, most likely less than 10%. This is an opportunity for orthopedic surgeons who embrace the science of hip arthroscopy and pursue educational opportunities while incorporating the services into their practice. Time will reveal the true impact.
Significant promise
The incorporation of new technology into orthopedic practices is an important process. We need to pay attention to the new ideas and concepts that hold significant promise for better patient care. We want to look for procedures and technology with scientific support. Our desire to learn and use new tools should be further encouraged by the evidence of improved efficiency of the treatment with a higher rate of consistent results and a reduction of complications. We need to avoid incentives that are seductive, but without evidence, as it is in the best interest of patients and the health care system.
Orthopedic surgeons need to develop a personal process to integrate new ideas and techniques into patient care and remain focused on the science and educational process. It is critical they understand the social, financial and ethical pressures that can distort the decisions away from what is truly in the best interest of patients.
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Disclosures: Romeo receives royalties, is on the speakers bureau and a consultant for Arthrex Inc.; does contracted research for Arthrex Inc. and DJO Surgical; receives institutional grants from AANA and MLB; and receives institutional research support from Arthrex Inc., Ossur, Smith & Nephew, ConMed Linvatec, Athletico and Miomed.